Pain-related Guilt in Low Back Pain

OBJECTIVES: Identifying mechanisms that mediate recovery is imperative to improve outcomes in low back pain (LBP). Qualitative studies suggest that guilt may be such a mechanism, but research on this concept is scarce, and reliable instruments to measure pain-related guilt are not available.METHODS: We addressed this gap by developing and testing a Pain-related Guilt Scale (PGS) for people with LBP. Two samples of participants with LBP completed the scale and provided data on rates of depression, anxiety, pain intensity, and disability.RESULTS: Three factors were identified using exploratory factor analysis (n=137): "Social guilt," (4 items) relating to letting down family and friends; "Managing condition/pain guilt," (5 items) relating to failing to overcome and control pain; and "Verification of pain guilt," (3 items) relating to the absence of objective evidence and diagnosis. This factor structure was confirmed using confirmatory factor analysis (n=288), demonstrating an adequate to good fit with the data (AGFI=0.913, RMSEA=0.061). The PGS subscales positively correlated with depression, anxiety, pain intensity, and disability. After controlling for depression and anxiety the majority of relationships between the PGS subscales and disability and pain intensity remained significant, suggesting that guilt shared unique variance with disability and pain intensity independent of depression and anxiety. High levels of guilt were reported by over 40% of participants.DISCUSSION: The findings suggest that pain-related guilt is common and is associated with clinical outcomes. Prospective research is needed to examine the role of guilt as a predictor, moderator, and mediator of patients' outcomes

Diagnostic uncertainty and recall bias in chronic low back pain

Patients' beliefs about the origin of their pain and their cognitive processing of pain-related information have both been shown to be associated with poorer prognosis in low back pain (LBP), but the relationship between specific beliefs and specific cognitive processes is not known. The aim of this study was to study the relationship between diagnostic uncertainty and recall bias in two groups of chronic LBP patients, those who were certain about their diagnosis, and those who believed that their pain was due to an undiagnosed problem. Patients (N=68) endorsed and subsequently recalled pain, illness, depression and neutral stimuli. They also provided measures of pain, diagnostic status, mood and disability. Both groups exhibited a recall bias for pain stimuli, but only the group with diagnostic uncertainty additionally displayed a recall bias for illness-related stimuli. This bias remained after controlling for depression and disability. Sensitivity analyses using grouping by diagnosis/explanation received supported these findings. Higher levels of depression and disability were found in the group with diagnostic uncertainty, but levels of pain intensity did not differ between the groups. Although the methodology does not provide information on causality, the results provide evidence for a relationship between diagnostic uncertainty and recall bias for negative health-related stimuli in chronic LBP patients

Perceived Diagnostic Uncertainty in Pediatric Chronic Pain

In this review, we argue that perceived diagnostic uncertainty in idiopathic pediatric chronic pain patients and their parents is critically important for understanding pain cognitions, behavioral responses to pain, treatment choices, and outcomes during this developmental period. We include evidence from children (under 12 years) and adolescents (12-18 years). This period sets the stage for future experience of pain: two thirds of children and adolescents with chronic pain will become adults with chronic pain [30]. The prevalence of pediatric chronic pain is rising, and has been described as a growing epidemic [11]. Better understanding of this core issue through well-designed research with pediatric populations is therefore crucial

Diagnostic uncertainty, guilt, mood, and disability in back pain

Objective: In the majority of patients a definitive cause for low back pain (LBP) cannot be established, and many patients report feeling uncertain about their diagnosis, accompanied by guilt. The relationship between diagnostic uncertainty, guilt, mood, and disability is currently unknown. This study tested 3 theoretical models to explore possible pathways between these factors. In Model 1, diagnostic uncertainty was hypothesized to correlate with pain-related guilt, which in turn would positively correlate with depression, anxiety and disability. Two alternative models were tested: (a) a path from depression and anxiety to guilt, from guilt to diagnostic uncertainty, and finally to disability; (b) a model in which depression and anxiety, and independently, diagnostic uncertainty, were associated with guilt, which in turn was associated with disability. Method: Structural equation modeling was employed on data from 413 participants with chronic LBP. Results: All 3 models showed a reasonable-to-good fit with the data, with the 2 alternative models providing marginally better fit indices. Guilt, and especially social guilt, was associated with disability in all 3 models. Diagnostic uncertainty was associated with guilt, but only moderately. Low mood was also associated with guilt. Conclusions: Two newly defined factors, pain related guilt and diagnostic uncertainty, appear to be linked to disability and mood in people with LBP. The causal path of these links cannot be established in this cross sectional study. However, pain-related guilt especially appears to be important, and future research should examine whether interventions directly targeting guilt improve outcomes

Chasing the ghosts: the impact of diagnostic labelling on self-management and pain-related guilt in chronic low back pain patients.

clear diagnosis cannot be established; as a result patientsare given labels such as non-specific low back pain. Thereis some evidence to suggest that lack of a clear diagnosis isassociated with negative psychological, clinical andbehavioural outcomes. The main aim of this study was toexamine CLBP patients’ understanding, feelings andbehaviour in response to their diagnostic labels. Semistructuredinterviews were conducted with twenty CLBPpatients who were recruited from one osteopathic and onepain management clinic in the UK. Sampling, datacollection and analysis were driven by a grounded theoryapproach. Data were analysed through four stages ofcoding: open, selective, axial and theoretical coding. Datacollection and coding continued until data achievedsaturation. Results indicated that lack of a clear diagnosis isassociated with distress, further treatment seeking anduncertainty. It also influenced participants’ perception oftheir social relationships; having visible evidence and aclear diagnosis gave patients’ pain more social credibility.Participants reported feeling guilty about the consequencesof their pain to themselves and others, and for failing torecover. Overall, participants’ narratives suggest that atleast for some, absence of a clear diagnosis hasconsiderable negative implications. The goal of the studywas to inform clinicians and policy makers about theimpact of diagnosis on CLBP patients’ adjustment andemotional burden; findings suggest that legitimising thepain experience is of prime importance to CLBP patients

The relationship between pain, disability, guilt and acceptance in low back pain: a mediation analysis

Pain-related guilt is a common yet unexplored psychological factor in low back pain (LBP). It has recently been linked to greater depression, anxiety and disability in LBP, hence an understanding of how it can be managed in the presence of pain and disability is necessary. Since acceptance of pain has been shown to be associated with improved outcomes in chronic pain, we examined whether it might also help reduce guilt in people with LBP. To this end, a series of mediation analyses were conducted on data from 287 patients with chronic LBP, in which acceptance of pain was tested as a mediator of the relationship between pain/disability and guilt. Results showed that acceptance of pain reduced the impact of pain/disability on pain-related guilt in all mediation analyses. Pain-related guilt might be a potential target for acceptance based interventions, thus this relationship should be further tested using longitudinal designs